Alan Dietzek

Endovenous radiofrequency ablation for the treatment of varicose veins.

Chronic venous insufficiency (CVI) is the most common vascular disease and represents a significant health care problem in the United States. Reflux of the great saphenous vein is the most common cause of this condition, whose symptoms include varicose veins, leg swelling, skin discoloration, and ulceration. The traditional treatment of this condition is saphenofemoral ligation with stripping of the saphenous vein followed by varicose vein removal, if necessary. Recent advances in minimally invasive endovenous therapy have led to the development of catheter-based radiofrequency ablation (RFA) of the saphenous vein, which has gained an increasing acceptance in clinical practice. Endovenous RFA was introduced into clinical practice in Europe in 1998 and in the United States in 1999. Since then, over 250,000 procedures have been performed worldwide. Procedure safety and efficacy are well understood, with over 60 publications on the subject in the peer review literature, including four randomized trials comparing this technology with traditional vein stripping surgery. With the advent of tumescent anesthesia, the majority of RFA procedures are now performed in an office setting. This article examines the current technology using RFA in saphenous vein ablation with the Closure catheter system. Procedural techniques and clinical outcome using RFA in saphenous vein ablation are discussed. Clinical data comparing RFA versus saphenous vein stripping are also examined. Lastly, the clinical utility of a new RFA catheter, ClosureFAST, is discussed. ClosureFAST is a new generation of RFA catheter and has exhibited significant improvement in the ease of use and the procedure speed over the previous generation catheters while maintaining the favorable patient recovery profile seen with the RFA technology.

Unusual presentation and treatment of spontaneous celiac artery dissection

The management options of an isolated celiac artery dissection include medical, open surgical, and endovascular techniques. Which strategy is chosen depends on the severity of the dissection, collateral circulation to the liver, the patients hemodynamic status, and the surgeons expertise. We describe an unusual case of celiac artery dissection involving splenic and hepatic arteries complicated by hemorrhage. The patient was successfully treated by coil embolization of the splenic and gastric branches. Hepatic arterial blood flow was preserved with a stent graft extending from the origin of the gastroduodenal artery to the orifice of the celiac artery.

Reporting standards of the Society for Vascular Surgery for endovascular treatment of chronic lower extremity peripheral artery disease: Executive summary

Recommended reporting standards for lower extremity ischemia were last published by the Society for Vascular Surgery in 1997. Since that time, there has been a proliferation of endovascular therapies for the treatment of chronic peripheral arterial disease. The purpose of this document is to clarify and update these standards, specifically for reports on endovascular treatment. The document is divided into sections: Claudication Reporting, Critical Limb Ischemia Reporting, Preintervention Assessment and Nonanatomic Treatment, Intervention, Outcome Measures - Procedural, Outcome Measures - Disease Specific, and Complications.

Endovascular Hypogastric Artery Preservation During Endovascular Aneurysm Repair: A Review of Current Techniques and Devices

Despite the improvement in endovascular techniques, one aspect of aneurysmal disease that continues to be challenging is the management of aortoiliac aneurysms. Sacrificing the hypogastric artery (HGA) for effective treatment is not without sequelae, which may include buttocks claudication, colonic ischemia, spinal cord ischemia, as well as buttock and scrotal necrosis. This should be taken into consideration particularly in patients with previous intervention or potential additional future interventions. This review describes the current endovascular techniques for preservation of HGA perfusion.

Iatrogenic May–Thurner Syndrome After EVAR

May-Thurner syndrome (MTS) is caused by compression of the left iliac vein between the right common iliac artery and the body of the fifth lumbar vertebra, resulting in hemodynamic compromise to venous return and intimal hyperplasia of the vein from chronic pulsatile compression. We report a case of MTS resulting from placement of an aortic stent graft for aneurysm repair. A higher index of suspicion and a more comprehensive initial venous duplex investigation, which should include the suprainguinal veins, should be considered in those patients with new onset of unilateral limb swelling after endovascular aneurysm repair (EVAR).

Pharmacomechanical thrombectomy: 2015 update

ABSTRACT Pharmacomechanical Thrombectomy (PMT) is recognized as a recent advancement in the treatment of lower extremity deep venous thrombosis (DVT). Evidence for the use of this modality is growing rapidly, primarily based on anecdotal experience and large case series. Currently, the majority of patients with lower extremity DVT are treated with anticoagulation or compressive therapy without adjunctive surgical or interventional procedures. This article reviews the current evidence supporting the use of PMT over catheter directed thrombolysis or simple anticoagulation and the expected benefits that can be realized from each modality. In addition the relevant unique characteristics to each device currently available are described focusing on mechanism of action and potential side effects.

The fate of endovascular aortic aneurysm repair after 5 years monitored with duplex ultrasound imaging

Background: Interventions for aortic aneurysm sac growth have been reported across multiple time points after endovascular aortic aneurysm repair (EVAR). We report the long‐term outcomes of patients after EVAR monitored with duplex ultrasound (DUS) imaging with respect to the need for and type of intervention after 5 years. Methods: We report a series of patients who were monitored with DUS imaging for a minimum of 5 years after EVAR. DUS imaging was performed in an accredited noninvasive vascular laboratory, and computed tomography angiography was only performed for abnormal DUS findings. Results: There were 156 patients who underwent EVAR with follow‐up >5 years (mean, 7.5 years; range, 5.1‐14.5 years). Interventions for endoleak, graft limb stenosis, or thrombosis were performed in 44 patients (28%) at some time during follow‐up. Of the 156 patients, 34 (22%) underwent their first intervention during the first 5 years (25 endoleaks, 9 limb stenoses, or occlusions). Four ruptures occurred, all in patients with their first intervention before 5 years. The remaining 10 patients (6%) underwent a first intervention >5 years after implantation: 3 for type I endoleak, 2 for type II endoleak with sac expansion, 2 for combined type I and II endoleaks 2 for type III endoleak, and 1 unknown type. Conclusions: Long‐term follow‐up of EVAR (mean, 7.5 years) revealed that approximately one in four patients will require intervention at some point during follow‐up. First‐time interventions were necessary in 22% of all patients in the first 5 years and in 6% of patients after 5 years, highlighting the need for continued graft surveillance beyond 5 years. All patients who had a first‐time intervention after 5 years underwent an endoleak repair; none of these patients had a thrombosed limb or a rupture as a result of the endoleak.

Contiguous bilateral head and neck paragangliomas in a carrier of the SDHB germline mutation

Paragangliomas are extremely rare neoplasms with multicentric presentation usually linked to familial tumor syndromes. This patient presented with the uncommon combination of concurrent bilateral carotid body tumors and a unilateral glomus jugulare mass that demonstrated vascular continuity. During treatment, the patient was found to be heterozygous for the SDHB germline mutation, an autosomal dominant genotype of the familial paraganglioma syndromes associated with increased malignancy. The unique profile of the SDHB patient as regards primary evaluation, surgical considerations, and extended surveillance was explored and has led to a proposed treatment algorithm for these patients.

Polymyalgia Rheumatica with Bilateral Subclavian Artery Stenosis

The overlap between polymyalgia rheumatica and giant ell arteritis has prompted physicians’ attention since the early 970s. Polymyalgia rheumatica occurs in approximately 0% of patients with giant cell arteritis, and approximately 5% of patients with polymyalgia rheumatica develop giant ell arteritis. Some experts consider polymyalgia rheuatica and giant cell arteritis to be different manifestations f the same pathologic process. Although the association of cclusive vascular disease is well known in giant cell areritis, it is not considered to be a typical manifestation of olymyalgia rheumatica. A 66-year-old woman presented to our rheumatology ractice in May 2007 with proximal muscle pain and tiffness of 1 year’s duration. The patient also reported cute onset of tingling with bluish discoloration in the ailbeds and fingertips of her left hand, exacerbated with verhead activity. She denied any headaches, vision hanges, scalp tenderness, or jaw claudication. Physical xamination revealed warm hands and good capillary efill in all digits despite a diminished right radial artery ulse and nonpalpable left radial artery pulse. She had ood pulsation without tenderness over the temporal areries. Laboratory test results showed a normal complete lood count, elevated erythrocyte sedimentation rate of 7 mm/H, C-reactive protein of 32.4, negative rheumaoid factor and antinuclear antibody, and normal creatine hosphokinase. Polymyalgia rheumatica was diagnosed, and the paient was started on prednisone 10 mg twice per day for week, followed by 10 mg daily. There was significant mprovement in her proximal arthralgias and myalgias, ut left arm claudication persisted. Doppler ultrasound of

Acute upper extremity arterial thrombosis and stroke in an unresected pheochromocytoma

Pheochromocytoma is a rare cause of hypertension in the general population. Only isolated reports show an association with acute obstructive arterial thrombosis. A 50-year-old chronically noncompliant woman with a known unresected pheochromocytoma presented to the emergency department with ataxia. Imaging confirmed a right-sided ischemic stroke. During her hospital stay, the patient developed signs consistent with acute right upper extremity ischemia resulting from occlusion in the distal right subclavian, axillary, and proximal brachial arteries. Emergent open thrombectomy was successfully performed. In patients with an unresected pheochromocytoma, one must consider acute arterial thrombosis as a rare but potentially limb-threatening and even life-threatening complication.